Patient Registration Form
MERCY HOSPITAL
Please return this form to mercy hospital at least one week prior to your operation/procedure date
Your Details (to be completed by patient)
Title (please circle): Mr Mrs Ms Miss Dr Other
Gender: Male
Legal First
Name(s):
Date of Birth:
Family Name:
Marital Status:
Previous Name:
Occupation:
NZ Resident: Yes
Country of Birth:
No
Female
/
/
NHI No: (if known)
Residential Address:
Postal Address (if different from above):
Phone: Home (
)
Work (
)
Mobile (
)
Email:
Language Spoken:
IF FAXING OR SCANNING SEND BOTH SIDES.
Ethnic Group:
Interpreter Required: Yes
No
Interpreter services must be arranged through your
surgeon’s rooms prior to admission
If visiting from overseas what is your address while staying in NZ?
(
Phone:
)
Emergency Contact person
Name:
Gender: Male
Female
Relationship to Patient:
Residential Address:
Phone: Home (
)
Work (
)
Mobile (
)
Health Insurer
Name of Insurer:
Policy Type:
Membership No:
Prior Approval No:
Is your surgery covered by ACC: Yes
No
ACC Approval Granted: Yes
ACC Claim No:
ACC Office:
No
ACC Case Manager:
Family Doctor
Name:
Address:
Phone:
(
)
Surgeon/Specialist
Name:
Date of Admission:
/
/
Time of Admission:
Prescription Cards
High Use Health Card
Expiry Date:
/
Community Services Card
Expiry Date:
/
Prescription Subsidy Card
Expiry Date:
/
Other
Expiry Date:
/
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MA056M_12/14
Patient Registration Form
MERCY HOSPITAL
ACC Claims
Contract Claim:
If your medical operation/procedure is an ACC Contract Claim, ACC will pay the hospital directly for all hospital and specialist’s costs
excluding personal expenses. Personal expenses, such as toll calls, drinks trolley beverages and visitor meals are required to be paid
for on discharge.
Individual Claim:
If your medical operation/procedure is an individual ACC Claim, a copy of the ACC Letter of Approval must be received by Customer
Support prior to Admission. ACC does not cover full costs of hospitalisation. A payment will be required on admission for the
estimated difference.
Part ACC/Part Insurance:
Proof of prior approval is required on admission for the portion of your procedure that is covered by insurance. If you are not insured,
you will be required to pay a portion of the estimated hospital costs on admission. For further details on ACC reimbursement
practices please ask your ACC case manager.
Payment of Hospital Costs
For further information please refer to the Patient Information booklet
Payment will be made by
credit card
bank cheque
cash
EFTPOS
other*
* Personal cheques are accepted by prior arrangement only. Personal cheques must be deposited five clear working days prior to
admission to the hospital to allow for clearance.
If you have no insurance, you will be required on admission, to pay the full estimated cost of the operation/procedure
We strongly recommend you contact our Customer Support Team 09 623 5700 for an estimate of the hospital costs
prior to admission
Y
ou understand and give consent that relevant information may be supplied to an external credit reporting agency to obtain
a credit report
You agree you are responsible and will pay for all costs incurred in connection with your treatment
You understand that MercyAscot may notify a credit reporting agency and/or instruct a debt collection agency should you
default on any payment due by you to MercyAscot
You understand that any collection and/or legal costs incurred in recovering any debt will be charged to you
Personal Property
You understand and agree that MercyAscot is not and will not be responsible for loss of or damage to any personal property (including
jewellery, dentures, watches, rings, glasses) which you may bring into the hospital
Y
ou consent to MercyAscot sharing relevant information that is related to your healthcare and as required by third parties such as
Health Insurers, Medical Specialists, ACC, and for quality and audit purposes
To the best of your knowledge the information you have supplied to MercyAscot is correct.
Signature:
Print Name (in full:)
Date:
/
/
Please return this form TO MERCY HOSPITAL at least one week prior to your operation/procedure date
(mercybookings@mercyascot.co.nz or See page 4 of Patient Information booklet)
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